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2 NAVIGATING NEXT STEPS IN HEALTH CARE REFORM There s a constant stream of changes and updates related to health care reform, and it s easy to lose track of what it all means for your business. Wouldn t it be great to have a GPS guide with turn-by-turn directions for health care reform? Every small business has a unique set of circumstances and challenges when it comes to health benefits, and on top of that, states may have health exchange implementation nuances that differ somewhat from the standard Affordable Care Act (ACA) provisions you hear about in the news every day. Before making key decisions, you need a clear understanding of the choices and responsibilities relevant to you as a Vermont business. That s why it s important to keep up with new developments in Vermont s health insurance Marketplace in 2014 and beyond. HEALTH CARE REFORM SNAPSHOT Vermont Health Connect Marketplace opened in October 2013 for individuals and small businesses with 50 or fewer employees. In December 2013, premium processing and payment functions were delayed for small businesses enrolling through the Marketplace. To ensure continuous coverage for employees, current 2013 plans have been extended until these functions are operational. (Note that small groups enrolling directly through an insurer were not affected.) WHICH WAY TO GO? Read on for a quick tour of: The new health insurance Marketplace model Vermont Health Connect Marketplace timeline What is a qualified health plan? Plan choice models for employers Tax incentives and penalties Questions and answers Temporary extension of coverage to March 31, 2014, to allow individuals and small businesses more time for enrollment in Marketplace plans. Small businesses have the option to enroll in Vermont Health Connect plans directly through an insurer or via the Marketplace when the premium processing and payment functions are fully operational in Small businesses with up to 100 employees will be able to offer coverage for employees through Vermont Health Connect in The state plans to implement a universal health care system in PAGE 2 An individual mandate requires everyone (with few exceptions) 1 to purchase health insurance or pay a penalty. There s no ACA penalty for small businesses with fewer than 50 employees that do not offer coverage to employees. Tax credits are available for small employers that provide coverage and meet certain requirements. Navigators, In-Person Assistors, Certified Application Counselors and brokers will help Vermonters use the Marketplace.

3 VERMONT HEALTH CONNECT Vermont Health Connect Marketplace is a state-based Marketplace that will serve the health insurance needs of Vermonters. It is a stepping stone on the way to a single-payer system in the state that intends to provide universal health care coverage for all residents under Green Mountain Care beginning in This means that Vermont Health Connect (and eventually, Green Mountain Care) will be the primary Marketplace for health insurance in Vermont. What is a small group? For the purposes of enrollment and health care reform applicability in 2014, states can define small group as either up to 50 or up to 100 full-time employees. Vermont employers with up to 50 employees will be eligible to buy plans through the Marketplace, and this expands to employers with up to 100 employees in (Sole proprietorships will be considered individuals for the purposes of exchange eligibility.) Vermont defines a full-time employee as someone who works 30 or more hours per week anyone who works less than 30 hours per week is not counted. BEGINNING IN 2014 Health exchanges will serve as regulated marketplaces where individuals and businesses can shop for health insurance plans. Some states have chosen to run their own health exchanges, while others will default to a federally facilitated exchange or participate in a partnership exchange with the federal government. What is community rating? Federal guidelines require a community rating system for small group and individual plans. Premiums may vary only by individual/family (number of persons covered), geographic area, age and tobacco use not health status. Vermont has a pure community rating system in place which exceeds federal guidelines (has a higher level of consumer protection), so there will likely be no change in how small groups are rated going forward. What is a SHOP exchange? The ACA included provisions for a Small Business Health Options Program (SHOP) exchange, which may help reduce rate volatility for small businesses by pooling together a larger base of insured participants. In Vermont, small groups and individuals will be merged to form a larger pool of insured Vermonters. Through the Marketplace, employers will have the opportunity to compare available health plans and select a range of options for employees to choose from. Employers will decide how much to contribute toward employee plans based on: 1) a percentage of the premium of a benchmark plan the employer chooses; 2) a fixed percentage for all plans offered (e.g., 70 percent employer/30 percent employee); or 3) a fixed dollar amount/defined contribution, which employees can apply toward the plan of their choice. MARKETPLACE TIMELINE OCTOBER 1, 2013 Open enrollment began (individual/family enrollment runs through March 2014, with groups being able to enroll whenever their current plans expire in 2014) MARCH 31, 2014 Open enrollment ends (and any plans that were temporarily extended will expire) 2016 Marketplace open to employer groups of 100 or fewer DECEMBER 31, 2013 Application deadline for Marketplace coverage to start January 1, 2014 JANUARY 1, 2014 Coverage begins for Vermont Health Connect plans (except for those individuals and small groups with 2013 coverage extended) NOVEMBER 15, 2014 Next open enrollment starts 2017 Marketplace open to employer groups of all sizes PAGE 3

4 WHAT IS A QUALIFIED HEALTH PLAN? The ACA includes a number of patient protections designed to help Americans gain access to affordable health coverage, such as guaranteed issue, no pre-existing condition exclusions, no lifetime caps on coverage and other protections. Other key benefits: Dependent coverage All health plans that provide dependent coverage of children are required to extend coverage to children up to age 26. Preventive care Health plans (non-grandfathered 2 ) must cover preventive services and eliminate cost-sharing for preventive care provided by an in-network provider. Women s health Health plans (non-grandfathered 2 ) must cover certain women s health services with no cost-sharing. Health plans sold through the state exchanges will follow new coverage and benefit rules for insurers (often referenced as Qualified Health Plans in the ACA) starting in Insurers provide a minimum set of essential health benefits and follow established limits on cost-sharing. Plans will be offered in a tiered format with metal levels (bronze, silver, gold and platinum) with several plans at each level to choose from. Employers with fewer than 50 employees are not required by law to offer health insurance, contribute to employee coverage, or to offer coverage to dependents. Large group and self-insured plans do not have to meet the same requirements, but employers with 50 or more full-time equivalent (FTE) employees may face penalties under the ACA for not offering minimum coverage (insurance that covers at least 60 percent of the cost of benefits) and is affordable to employees. 3 Note: The federal government delayed the Employer Shared Responsibility Provisions until As a result, large employers have an extra year to comply with this part of the law. The penalties imposed on large employers for not offering affordable coverage (called Employer Shared Responsibility Payments) will take effect in PAGE 4

6 PLAN CHOICE MODELS FOR EMPLOYERS The Vermont Health Connect Marketplace includes multiple options for plan selection, allowing employers some control over the options available in their plan and how much to contribute toward employee coverage. The following example shows two choice models. EMPLOYER PLAN SELECTION MODELS Employer selects one insurer Full employee choice of all plans Metal Level Insurer A Insurer B Platinum 90% Plan 1 Plan 1 Gold 80% Plan 2 Plan 2 Silver 70% Plan 3 or 4 Plan 3 or 4 Bronze 60% Plan 5 or 6 Plan 5 or 6 THE TIPPING POINT The choice Vermont employers face is whether to maintain health coverage as an employee benefit or shift to a model where employees purchase individual plans. Small businesses with 50 or fewer full-time employees may offer coverage through the Marketplace, purchase coverage directly from an insurer or send employees to the Marketplace for individual coverage. Some key considerations in the decision to drop coverage: Employee eligibility for subsidies on the exchange (based on household income) Increasing wages to help employees afford buying coverage on their own Tax implications (losing corporate tax exemption, paying additional payroll taxes) Employer eligibility for tax credits/incentives to offer small group coverage The impact on recruitment and retention efforts, as well as employee wellness PAGE 6 Offer group coverage EMPLOYER CHOICES Send employees to through the the Marketplace for Marketplace (when individual coverage available in 2014) Purchase a qualified group plan directly through an insurer

7 TAX INCENTIVES AND PENALTIES Provisions in health care reform law include financial incentives and tax penalties for individuals and businesses. These provisions may affect your business and/or your employees, so you should consider the potential outcomes with your tax or legal advisor. Individuals and families Incentive Premium assistance for individuals and families: Available for those who meet income requirements (139 to 400 percent Federal Poverty Level). Those who meet this income level requirement may obtain a tax credit that can be applied to any level exchange plan. Individuals with income at or below 138 percent Federal Poverty Level would be eligible for Medicaid, assuming state participation in Medicaid Expansion. Cost-sharing reduction: For those at or below 250 percent Federal Poverty Level, the ACA provides for reduced cost sharing to protect those at lower income levels from high costs at the point of service. The state of Vermont offers expanded financial assistance including cost-sharing reductions for those up to 300 percent Federal Poverty Level. Penalty Individual mandate: The penalty for not having minimum coverage in 2014 will be $95 per adult and $47.50 per child (up to $285 for a family) or 1 percent of taxable income, whichever is greater. In 2015: $325 per adult/$ per child (up to $975/family) or 2 percent of family income. In 2016: $695 per adult/$ per child (up to $2,085/family) or 2.5 percent of family income. The penalty amounts will adjust annually in future years. Small employers Tax credits for small businesses: Eligible employers with fewer than 25 FTE employees may earn tax credits that cover up to 50 percent of premiums in 2014 (up to 35 percent for small tax-exempt employers) for up to two years. For small employers with fewer than 50 employees, there are no penalties for not offering coverage to employees or their dependents. Large employers Employer Shared Responsibility Payment: Employers with 50+ FTE employees must offer minimum coverage that pays for at least 60 percent of the cost of covered benefits and meets affordability standards or they will be subject to penalties in SMALL BUSINESS TAX CREDIT ELIGIBILITY Below are some basic eligibility guidelines for employers; see your tax advisor for more information. Fewer than 25 full-time equivalent employees (phases out between 10 and 25 workers). Average annual wages below $50,000 (phases out between $25,000 and $50,000). Employer pays at least 50 percent of the premium for workers based on the single (not family) rate. Note: For the purposes of determining eligibility for tax incentives and penalties, the basis for determining the relevant number of employees is based on full-time equivalent employees (FTE), which includes part-time employees in its calculation. This means that an employer that is considered a small group for the purposes of exchange participation based on the number of full-time employees working 30+ hours/week, may be subject to penalties (effective in 2015) if the employer has 50 or more FTEs using IRS calculations. Consult with your tax or legal advisor to assess your situation. PAGE 7

8 HEALTH INSURANCE MARKETPLACE Q & A PAGE 8 Here are some common questions small group employers have posed in regards to the implementation of the Vermont Health Connect Marketplace: Q. What help is available for understanding the options available through the Marketplace? A. Navigators, In-Person Assistors (IPAs) and brokers are trained by the state to provide enrollment assistance to employers and individuals who apply for health insurance through the Marketplace. Q. How will the Marketplace handle enrollment assistance and employee support? A. Employees will have access to a state-run customer service hotline staffed by trained professionals who can address their questions and concerns (such as understanding basic benefit offerings or addressing off-cycle enrollment). Q. When does it make sense to discontinue coverage and send employees to the individual Marketplace? A. This critical choice depends on company size, type of business, employee population (whether employees might qualify for tax subsidies), employer tax credits, cost of coverage, the value employees place on health benefits through work as well as other factors. Before discontinuing coverage, employers may also consider the impact of raising wages so employees can afford buying coverage on their own if they are unlikely to qualify for subsidies. Q. If my current small group plan renews in January 2014, will I be able to keep my current plan? A. The state of Vermont announced a temporary extension of existing coverage to March 31, 2014, allowing more time for individuals and small businesses to enroll in the Marketplace. Q. Can individuals enroll in exchange plans at any time during the year? A. Most individuals and families will be able to enroll in plans during the first open enrollment period from October 1, 2013 to March 31, Going forward open enrollment will begin November 15, 2014, for plans effective the next January. Vermonters who are eligible for Medicaid or Dr. Dynasaur can enroll at any time throughout the year. STAY INFORMED Communicate with employees. Decision-support tools and resources can help employees prepare for the choices they need to make. Collaborate with experts your legal and financial advisors, broker or insurance plan representative. Contact MVP to schedule an informational Health Exchange briefing for you, your management team or your employees. Stay on top of health care reform news and updates. Sign up for MVP s monthly e-newsletter Health Care Business Review at discovermvp.com/hcbr

9 Q. What if employees can t afford to purchase the individual plans that are available through the Marketplace? A. The Marketplace provides access to income-based premium assistance and cost-sharing credits for those who qualify and purchase individual coverage on the exchange. Catastrophic health plans are also available via the Marketplace for young adults under age 30 and those for whom coverage would otherwise be unaffordable. Q. Can my group enroll in a plan through the Marketplace at any time during 2014 (prior to our natural renewal anniversary date)? A. Eligible small businesses can enroll at any time during 2014 (after the premium processing and payment functions are operational for group coverage through Vermont Health Connect). For subsequent years, the open enrollment period will be the same as for individuals, with benefits and rates based on the calendar year. OPEN ENROLLMENT Open enrollment in the Marketplace began October 1, 2013, for plans effective in Individuals and small businesses can obtain enrollment assistance from Navigators, In-Person Assistors, by phone or directly through the Marketplace website. Plan enrollment applications will be available in electronic and hard copy form for submission. State guidelines, requirements and rules may change or be refined over time for the most current information, visit: healthconnect.vermont.gov Contact your MVP representative for a personalized presentation on the new ACA requirements for employers. For more information, subscribe to the Health Care Business Review newsletter at discovermvp.com/ HCBR 1 Exceptions to the requirement to maintain the minimum essential coverage include: inability to pay for coverage that is more than 8 percent of household income; income that is below the tax filing threshold; religious reasons; not present in the United States; incarceration; possession of a hardship waiver; lack of coverage for less than three months out of the year. 2 Special grandfathered group plan status, with fewer reform requirements, is an option for small businesses with plans in place before March 23, 2010, that wish to keep their current plans. 3 For determining the Employer Shared Responsibility Payment effective in 2015, FTEs are counted as full-time employees who work an average of 30 or more hours/week or an equivalent combination of full-time and part-time employees. Large employers offering coverage will be subject to penalties if the employer s plan is unaffordable (the employee contribution for self-only coverage exceeds 9.5 percent of household income) or the plan pays for less than 60 percent of covered expenses and one or more employees enroll in an exchange plan and receive premium credits. Source: IRS Questions and Answers on Employer Shared Responsibility Provisions Under the Affordable Care Act, Questions-and-Answers-on-Employer-Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act PAGE 9

10 ABOUT MVP For more than 30 years, MVP Health Care has been a regional not-for-profit company committed to our members, our employer groups and the communities we serve. With innovative options and a focus on wellness, we work hard to deliver great value and great customer service. EPO and PPO plans High-Deductible Health Plans (HDHP) Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Flexible Spending Account (FSA) Wellness programs and incentives Pharmacy tools Medicare Advantage Defined contribution benefits Alternative funding solutions Discover what we can do for you. FIND US ON PAGE 10 This publication does not constitute professional medical, legal, accounting or financial advice. Although it is intended to be accurate, neither the publisher nor any other party assumes liability for loss or damage due to reliance on this material. If you have medical, legal, accounting or financial questions please consult with the appropriate professional for guidance. Images may be from one or more of these sources: Thinkstock, istock, Fotolia MVP Health Care. All Rights Reserved. Health benefit plans are issued or administered by MVP Health Plan, Inc.; MVP Health Insurance Company of New Hampshire, Inc.; MVP Health Plan of New Hampshire, Inc.; MVP Select Care, Inc.; MVP Health Services Corp.; Preferred Administrative Services, Inc.; Preferred Assurance Company, Inc.; and Hudson Health Plan, Inc., operating subsidiaries of MVP Health Care, Inc. Not all plans available in all states. HealthBenefitExchangeVermont_B (4/13) _updated 12/13

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